Symptoms or Symptom-Based Scores Cannot Predict

Acute Otitis Media at Otitis-Prone Age
WHAT’S KNOWN ON THIS SUBJECT: Acute symptoms and scores
are used as tools in the diagnosis and management of AOM.
However, their predictive value for AOM is not known for young
children whose parents suspect AOM.
WHAT THIS STUDY ADDS: The occurrence, duration, and severity
of symptoms are not predictive for AOM at otitis-prone age.
Symptom-based scores cannot differentiate AOM from
respiratory tract infection. Tympanic-membrane examination is
crucial for the diagnosis and scoring of AOM.

abstract
OBJECTIVE: Acute symptoms are used to diagnose and manage acute
otitis media (AOM). We studied whether AOM could be predicted by the
reason for parental suspicion of AOM or by the occurrence, duration,
and/or severity of symptoms. We also compared scores including or excluding tympanic-membrane examination of children with and without AOM.
PATIENTS AND METHODS: Children aged 6 to 35 months with parental
suspicion of AOM were eligible. Before tympanic-membrane examination, we registered on a structured questionnaire the reason for parental suspicion of AOM, symptoms, and score components.
RESULTS: Of 469 children studied, 237 had AOM and 232 had respiratory tract infection without AOM. The most common reason for parental
suspicion of AOM, restless sleep, was not predictive for AOM (RR: 1.0
[95% CI: 0.8 –1.2]), nor was ear-rubbing (relative risk [RR]: 0.7 [95%
conﬁdence interval (CI): 0.5–1.0]). Neither the occurrence of fever (RR:
1.2 [95% CI: 1.0 –1.4]) nor the highest mean temperature within 24
hours predicted AOM, nor did the occurrences of ear-related, nonspeciﬁc, respiratory, or gastrointestinal symptoms. The duration and severity of symptoms were not predictive for AOM, although rhinitis
lasted longer and conjunctivitis was more severe in children with AOM.
The clinical/otologic score (median: 4.0 vs 2.0; P ⫽ .000) and the AOM
total-severity index (11.0 vs 6.0; P ⫽ .000), both including symptoms
and tympanic-membrane examination, were higher in those with AOM.
The AOM severity-of-symptom scale, based solely on symptoms, was
equal in children with and without AOM (6.0 vs 6.0; P ⫽ .917).

CONCLUSIONS: AOM cannot be predicted by the occurrence, duration,
or severity of symptoms at otitis-prone age. Likewise, solely symptombased scores do not differentiate between respiratory tract infections
with or without AOM. Thus, tympanic-membrane examination is crucial
in the diagnosis and severity classiﬁcation of AOM in clinical practice
and research settings. Pediatrics 2010;125:e1154–e1161

e1154

LAINE et al

Downloaded from pediatrics.aappublications.org by guest on March 3, 2015

hyperemia. The highest measured temperature (ⱖ38°C)
within 24 hours was recorded.5 days).ARTICLES
Acute symptoms play a crucial role in
the diagnosis of acute otitis media
(AOM). and (3) symptoms and signs of
acute infection. Thus.
MD). and treatment
PEDIATRICS Volume 125. translucency. The study protocol was approved by the ethical committee of the
Hospital District of Southwest Finland. which is the age group
with the highest incidence of AOM. These symptoms. and which
ear had the worse status.
and no compensation for participation
was given. mucus
vomiting (retching and throwing up
swallowed mucus).5–8
Clinical experience gives the impression that symptoms occurring at the
time of AOM are variable.
the severity was classiﬁed as mild
or severe: excessive crying. we systematically assessed the middle-ear status
(position. microbiology. poor appetite. Ta¨htinen.
We also compared scores from recent
literature that included or excluded
tympanic-membrane examination of
children with and without AOM. McCormick. Parents evaluated their child’s overall condition
with the AOM-faces scale. MO) was used to document the
ﬁndings. children
aged 6 to 35 months were brought for
an outpatient visit because of parental
suspicion of AOM based on suggestive
symptoms.3 to study only 1 severity grade
of AOM. nasal congestion. All visits were free of charge. Of
the 5 study physicians.2 In
clinical trials of AOM. cough. decreased or
absent mobility. ear-rubbing. rhinitis. He agreed with
95% of our AOM diagnoses. Number 5. at worst within 24 hours and at the
time of the visit (used with the kind
permission of David P.12 scoring 1 to
7. restless
sleep. the otoscopy
score (8 grades) (OS-8)13. May 2010
of AOM at the primary care level. The duration of
symptoms was measured in days (with
an accuracy of 0.
there is a lack of data on the predictive
value of the occurrence. such as ear
pain and fever.
Symptom Questionnaire
Before tympanic-membrane examination. NY]). mobility of the tympanic membrane.9–11 All of
the studies have included children
with verbal skills. vomiting (throwing up partially digested foods and
drinks).4 and as the primary outcome in
randomized trials that assess the effect of antimicrobial treatment. After
telephone contact by parents. and severity
of 17 symptoms by using a standardized. Digital pneumatic video otoscopy (Jedmed. For the
occurrence and duration of fever. or airﬂuid interfaces). (2) at least 1 acute
inﬂammatory sign of the tympanic
membrane (distinct erythematous
patches/streaks or increased vascularity over full/bulging/yellow convexity).1 Parents base
their suspicion of AOM on the symptoms of their child. Only a few
studies have focused on symptoms of
AOM in the outpatient setting. the study physician asked the reason for parental suspicion of AOM and
the occurrence. and diarrhea. and Ruohola) made
more than 90% of the diagnoses and
had an excellent agreement (␬ values from 0. moderate.
Before examining the study population. all study physicians were
validated to assess the tympanicmembrane ﬁndings and the OS-8. we
also accepted the parents’ assessment of fever with no temperature
measurement. and
severity of symptoms in children aged
6 to 35 months. After careful cerumen removal. color. and possible airﬂuid interfaces) by using pneumatic
otoscopy (Macroview otoscope model
23810 [Welch Allyn]).aappublications. Skaneateles Falls.org by guest on March 3.92). structured questionnaire. and none have examined the severity of symptoms. In the following symptoms.
Scores
On the basis of our detailed symptom questionnaire and tympanicmembrane examination.
hoarse voice. abnormal color or
opacity not caused by scarring. and
irritability. we calculated
Downloaded from pediatrics. The guidelines advise physicians to use the severity of
symptoms to choose the most appropriate treatment (antimicrobial therapy versus observation option) of AOM
and to follow-up the episode of AOM. Severity was classiﬁed
as mild.80 to 0. light reﬂex. 2015
e1155
. are included in the diagnostic criteria of AOM. St
Louis.
PATIENTS AND METHODS
Study Population
This study was conducted between November 2006 and December 2008 and
was part of a project examining the diagnosis.
duration.
The diagnosis of AOM required 3 criteria: (1) middle-ear ﬂuid detected by
pneumatic otoscopy (at least 2 of the
following signs on the tympanic membrane: bulging position. duration. or severe for the
following symptoms: ear pain reported
by parents and the child’s verbal expression of ear pain.3. symptoms have
been used for severity scoring to assign children to different treatment
groups. less playful or active. 3 of us (Drs
Laine. and/or severity of symptoms. duration.
We studied the symptoms of children
in this otitis-prone age group when
their parents sought medical attention
because AOM was suspected.
Tympanic-Membrane Examination
The study physicians ﬁrst performed
tympanometry (MicroTymp2 [Welch Allyn. An ear-nosethroat specialist assessed the images and videos of 150 children
without knowing their symptoms
and/or our diagnosis. conjunctivitis.
Written informed consent was obtained from a parent of each child before any study procedure was performed. The aim
of this study was to ﬁnd out if AOM
could be predicted by the occurrence.

P ⫽ .
In fact.
Reasons for Parental Suspicion of
AOM
The most common reason for parental
suspicion of AOM was restless sleep. The AOM-SOS score
consisted of ear-rubbing. A score
range of 0 to 14 was the result.5–1.8 days [non-AOM group].
redness of tympanic membrane. scored as 0 (none). Furthermore. irritability. excessive
crying.
However. mucus vomiting.7 [95% CI:
0. and fever.0 –
1. and ⱖ39°C as 2 (a lot).
The statistical analyses were performed by using the SPSS 16.
Accordingly. for 48% (68 of 141) of children
with no previous AOM.
We did not analyze these 3 scores or
the AAP’s deﬁnition for illness severity
e1156
LAINE et al
if 1 or more components of a score
(except measured temperature) were
missing. excessive crying.
we used the modiﬁed AOM totalseverity index (AOM-Si) as suggested by
McCormick et al4 who used this score to
determine the severity of AOM for studying the treatment of nonsevere AOM only.508) (Fig 2) and the duration of fever (2. and severe or prolonged
rhinitis/cough were rare reasons
for parental suspicion and could not
predict AOM. restless sleep could not pre-
dict AOM (RR: 1.2 The child had severe illness if
ear pain (parentally reported and/or
reported by the child verbally) was
moderate or severe and/or the highest
temperature within 24 hours was
⬎39°C. Almost all parents
reported that their child had ear
pain. Characteristics of children in
the AOM and non-AOM groups are
shown in Table 1. conjunctivitis. Second. restless sleep. Duration.aappublications.2]) (Fig
1). Respiratory symptoms. 38.9°C as 1
(a little).0 statistical package (SPSS Inc. we assessed illness severity according to the American Academy
of Pediatrics (AAP) 2004 guidelines for
the diagnosis and management of
AOM. The likelihoods were estimated by calculating the relative risk
(RR) with respective 95% conﬁdence
intervals (CIs). Earrubbing tended to be more common in
children who did not have AOM (70%
[AOM group] vs 78% [non-AOM group]. The
occurrences of nonspeciﬁc symptoms
(irritability.4]). less playful or active. vomiting. rather.
The AOM-Si score (range: 1–14) was calculated by including the highest OS-8 in
pneumatic otoscopy (measuring the
severity of tympanic-membrane inﬂammation [range: 0 –7]) and the
highest AOM-faces scale (measuring
parental perception of their child’s
worst overall condition within 24
hours [range: 1–7]). We classiﬁed temperature of
⬍38°C as 0 (none). 61 children (26%) had unilateral or bilateral middle-ear ﬂuid. but
when ear-rubbing was a reason for suspicion. restless
sleep.org by guest on March 3.3 scores used in previous literature. AOM was improbable (RR: 0. Chicago.
In addition. the highest mean
temperature within 24 hours (38. Ear pain (parentally
reported or reported by the child verbally). The
symptoms of these 61 children did
not differ from those with completely
healthy ears. P ⫽ . IL). and for 52%
(169 of 325) of children with previous
AOM.9]). poor appetite.0]). the child had nonsevere illness.
The duration of symptoms had no predictive value for AOM in children having RTI with and without AOM except
for rhinitis that had lasted ⬃1 day
longer in those with AOM compared
with children with no AOM (Table 2).1 days [AOM group] vs
1.6 – 0. less
playful or active. If the child had had fever and
the temperature had not been measured within 24 hours.
listed for 134 of 468 (29%) children (data
missing for 1 child in the AOM group). and poor
appetite) were not predictive for AOM.050).2 [95% CI: 1.
Occurrence.0) created by Shaikh et
al16 to measure the outcome in clinical
studies of AOM. and
bulging position were scored from 0 to
3. including our categories mild and moderate). Third. fever. and
Severity of Symptoms
The occurrence of ear-related symptoms could not predict which children
had AOM (Table 2).0 [95% CI: 0.234)
did not differ between the groups. irritability.
The means were compared with the t
test and the medians with the MannWhitney U test. parental suspicion of AOM
proved to be correct for 51% of all children.8 –1.
RESULTS
The study population comprised 469
children: 237 had AOM (AOM group)
and 232 had respiratory tract infection
(RTI) without AOM (non-AOM group).
First. we used the clinical/otologic
score14 primarily developed by Dagan
et al15 to determine the severity of AOM
and to measure the treatment outcome of AOM (temperature.
and diarrhea could not predict which
children had AOM. The relationships between the scores were assessed by
Spearman correlation coefﬁcients. P ⫽ . In the non-AOM
group. 1 (a little. Parents suspected AOM because
of ear-rubbing in 64 children (14%). the latter
tended to have more severe symptoms (data not shown). nor could irritability that had evoked
parents’ suspicion of AOM in 84 children
(18%). 2015
.
Statistical Analysis
The proportions were compared with
␹2 test or Fisher’s test as applicable.0°C to 38. irritability suggested that the
child did not have AOM (RR: 0. we used the
AOM severity-of-symptom scale (AOMSOS) (version 3. for a total range of 0 –12).
or 2 (a lot.6°C [non-AOM
group]. we used the
highest measured mean temperature
of his or her study group. although children themselves
had rarely expressed it verbally. including our category severe). Occurrence of fever could
not predict AOM (RR: 1.
Downloaded from pediatrics.7°C
[AOM group] vs 38. Otherwise.7
[95% CI: 0.

087). bulging)
7 (erythema.
68% of children with AOM and 60% of
children without AOM would have been
categorized as having severe illness
(P ⫽ . The same applied to the scoring
of the overall condition of the child by
the AOM-faces scale.
Data were missing for 4 children in the non-AOM group. P ⫽
. n/N (%)
Current use of paciﬁer. According to the
AAP’s deﬁnition for illness severity.
d Tympanic membrane had full or bulging position in 90% (44 of 49) of the children. duration.547
. May 2010
severe in those children who had AOM
compared with those with only RTI.0 vs 6. of previous AOM episodes. Similarly. n/N (%)
Duration of breastfeeding. opaciﬁcation. n (%)
6–11 mo
12–23 mo
24–35 mo
Male gender. because symptoms are
used in the diagnosis and management of AOM. mean (range). The most
common reason given was restless
sleep.0. and
none of the reasons for suspicion
could predict AOM. we analyzed the
reasons parents had when they suspected AOM in their child.
Scores
The clinical/otologic score was signiﬁcantly higher in children who had AOM
than in children who had only RTI (median: 4.org by guest on March 3. Our study design requiring AOM
suspicion might explain why almost all
parents reported ear pain in their
child. no effusion)
2 (erythema. These results are
important.000).0.0 vs 6.001
. and gastrointestinal symptoms were equally severe in both groups
(Table 3).001
⬍. no
opaciﬁcation)
4 (erythema. mo
Age. moa
No. Number 5. n (%)
White
Caucasian-African
Age at ﬁrst AOM episode.
no bulging)
6 (erythema. mean (range). Only conjunctivitis was more
PEDIATRICS Volume 125.956
⬍. n (%)
0 (normal or effusion. opaciﬁcation with air-ﬂuid level. n/N (%)
A (more than ⫺100 dPa)
C (less than ⫺100 dPa)
B (no peak)
AOM Group
(N ⫽ 237)
Non-AOM Group
(N ⫽ 232)
16 (6–35)
16 (6–35)
87 (37)
103 (43)
47 (20)
130 (55)
93 (40)
98 (42)
41 (18)
122 (53)
237 (100)
0 (0)
10 (0–27)
230 (99)
2 (1)
10 (0–29)
68/237 (29)
130/237 (55)
31/237 (13)
8/237 (3)
129/237 (54)
129/236 (55)
68/236 (29)
126/237 (53)
8 (0–30)
73/229 (32)
107/229 (47)
37/229 (16)
12/229 (5)
131/229 (57)
89/229 (39)
60/228 (26)
134/229 (59)
8 (0–24)
0 (0)
0 (0)
0 (0)
0 (0)
206 (89)c
23 (10)
3 (1)
0 (0)
49 (21)d
0 (0)
81 (34)e
0 (0)
84 (35)
23 (10)
0 (0)
0 (0)
16 (7)
0 (0)
221 (93)
159 (69)
42 (18)
31 (13)
0 (0)
5 (2)
40 (17)
192 (81)
171 (74)
32 (14)
28 (12)
1 (0.547
.ARTICLES
TABLE 1 Characteristics of 469 Children With Parental Suspicion of AOM
Age. n/N (%)
Daycare attendance.001
⬍.
respiratory. and irritability did not
differ between children with and without
AOM (Fig 3). clear ﬂuid)
3 (erythema. complete effusion. fewer than one-ﬁfth
Downloaded from pediatrics.457
. n/N (%)
Tobacco-smoke exposure. air-ﬂuid level. although it
should be noted that it was not predictive for AOM.308
. mob
OS-8 score at the visit.917). The
AOM-Si score was likewise higher in
the AOM group than in the non-AOM
group (11. bulging. solely
symptom-based scores could not differentiate children with AOM from
those without AOM.
b
The severity of parentally reported ear
pain.0 vs 2.001
26/172 (15)
22/172 (13)
124/172 (72)
96/188 (51)
78/188 (41)
14/188 (7)
a
Data were missing for 77 children in the AOM group and 94 children in the non-AOM group. no erythema)
1 (erythema only.244
. Furthermore.aappublications. Furthermore.
opaciﬁcation. complete effusion. 2015
e1157
. P ⫽ . nonspeciﬁc. mean (range). P ⫽ .
the AOM-SOS score based solely on
symptoms was equal between the AOM
and non-AOM groups (6.
DISCUSSION
Our main ﬁnding was that the occurrence.
no bulging)
5 (erythema. and severity of symptoms did not predict AOM in children at
otitis-prone age when their parents
suspected AOM. complete effusion.9–11 In our
study.
c No effusion in 72% (148 of 206) of the children. n (%)
Normal
Retracted
Full or bulging
Quality of middle-ear ﬂuid. However.
For a new perspective.001
⬍. n (%)
No visible ﬂuid
Clear or serous
Cloudy
Purulent
Tympanogram (peak pressure). n/N (%)
0
1–3
4–6
⬎6
Sibling(s) in the household.0. n (%)
Race.
e All tympanic membranes had full position.623
.327
. the symptom that most disturbs
the parents’ own life.245
.4)
P
. In contrast.712
. the occurrence of parentally reported or the child’s verbal expression
of ear pain could not predict AOM.
Ear pain has been the symptom commonly associated with AOM. ear-rubbing. Parents of almost half of
the children suspected AOM on the
basis of a nonspeciﬁc symptom. child’s verbal expression of ear
pain.000) (Fig 4). the severity of ear pain did not
differentiate children with and without
AOM. bulla formation)
Position of tympanic membrane.

25
The occurrence. da
AOM
Group
Non-AOM
Group
P
1.945
.9.6
1.9.2 (1.026
.5)
1.5)
2.8–1.4
2.7
2. and severity
of nonspeciﬁc symptoms were equal in
children with and without AOM.591
.8–1.741
.9–11 the occurrence of fever did
not predict AOM in young children.21 As in
our study.318
.7–1. As others
have shown. nonspeciﬁc symptoms
are not predictive for AOM at otitisprone age.18
Shaikh et al16 excluded ear pain from
the AOM-SOS score.0 (0.3)
1.9–1.8 (0.28.0
3.8–1.427
.9
6.124
1.0 (0.27 but has a limited role in
predicting AOM because of its rare
occurrence.
of these young children verbally expressed ear pain. 2015
.
We found it surprising that earrubbing tended to be more common in
children without AOM than in children with AOM.9.20.9 However. we recommend
against using ear-rubbing as evidence of ear pain or as a sign of AOM.6–1.943
. we asked separately about actual vomiting and mucus
Downloaded from pediatrics.7 (0.809
. In previous studies. Baker19 reported that if earrubbing was a child’s only complaint. which was more severe in children with AOM than in
children with only RTI.223
.1.811
44 (19)
31 (13)
165 (70)
102 (43)
206 (87)
206 (87)
205 (87)
112 (47)
150 (63)
222 (94)
177 (75)
187 (79)
81 (34)
44 (19)
25 (11)
3 (1)
31 (13)
180 (78)
81 (35)
216 (93)
204 (88)
199 (86)
104 (45)
148 (64)
220 (95)
171 (74)
172 (74)
82 (35)
33 (14)
24 (10)
5 (2)
22 (10)
RR (95% CI)
for AOM
Mean Duration.025
.3)
1.9)
1.910
.2 (0.8
3.8
.5
2.0 (0.9.204
.org by guest on March 3. On the basis
of these results.0 (0.11
Gastrointestinal symptoms were not
predictive for AOM.0)
1.8–1. points to parental difﬁculties
with assessing ear pain in children at
this preverbal and otitis-prone age.661
.2)
1.2 (0.aappublications.0–1.1
3.0 (0. 30 in non-AOM group) suspected AOM for a miscellaneous
reason or for several reasons.29 However.17. n (%)
AOM Group
(N ⫽ 237)
Non-AOM Group
(N ⫽ 232)
P
219 (92)
213 (92)
.1 (0.8–1. a Parents of 62 children (32 in AOM group.6
2.
TABLE 2 Occurrence and Mean Duration of Symptoms in 469 Children With Parental Suspicion of
AOM
Symptom
Parentally reported ear
pain
Child’s verbal expression
of ear pain
Ear-rubbing
Fever
Irritability
Excessive crying
Restless sleep
Less playful or active
Poor appetite
Rhinitis
Nasal congestion
Cough
Hoarse voice
Conjunctivitis
Mucus vomiting
Vomiting
Diarrhea
a
Occurrences.800
. which. a ﬁnding that agrees
with previous study results.4
3. although pediatric textbooks describe
fever as indicative of AOM.9 (0.2
5.076
.5
3.712
.11
Respiratory symptoms could not predict AOM.
the occurrence of vomiting was more
than 10 times higher than in our
study.5)
1.3
.5
2.861
Duration of each symptom among those children who had the symptom.5
3.9
6. fever might be
associated with the viruses causing RTI
rather than speciﬁcally with AOM.
then no child had AOM.791
.9.0 (0.9
7.2–4.6
3.
Consistent with the results of previous
studies.11.5.5
2.3
2. Ear-rubbing has
been used almost as a synonym for
ear pain. infants may
rub their ear because of a blocked
ear or merely when becoming acquainted with their body.2 (1.1
3.22–24 The distribution of the
highest mean temperature in children
with and without AOM was surprisingly
similar. in young children.4.9–1.193
.8)
1.071
.6
5.4
2.4)
1.821
.9–1.7
1.6–0. with the exception of
conjunctivitis.598
.0 (0.3)
1.2)
0.7–1.134
.7–1.7 (0.8
2.4
3.3)
1. This ﬁnding disagrees with the results of Niemela¨ et
al.204
. and frequently with no infection.6
2.5
3.050
.4)
1.4)
0.0 (0. Furthermore. For this reason.11.4)
0.304
.3–1.7
0.9–1.FIGURE 1
RR for AOM according to the reasons for parental suspicion of AOM and the occurrence of each symptom in children diagnosed as having AOM (AOM group)
and in children with RTI without AOM (non-AOM group).9 who included children with any
e1158
LAINE et al
kind of acute illness. The so-called
conjunctivitis-otitis syndrome is well
known26. Nonspeciﬁc symptoms occur during viral
infections. fever usually has occurred
in less than half of the AOM population.1
1.377
.2)
1. as in our
results. duration.8
6.2
4.234
.260
.0–1.946
.219
0.17.6
.500
.

specifically to measure outcome in clinical
studies of AOM.
our physicians also used tympanometry
and had excellent interobserver agreement.
This study has several strengths. and antimicrobial agents may
cause mainly actual vomiting. illness severity could not predict the probability of
AOM.org by guest on March 3.31. mild. the AOM-SOS
score based solely on symptoms gave
equal scores to children having RTI
with and without AOM.2 Our AOM group had typical ﬁndings
of positive bacterial culture: full/bulging
position of tympanic membrane. we recommend validating scoring systems that would include
tympanic-membrane examination.24.
Downloaded from pediatrics.ARTICLES
FIGURE 2
The highest measured temperature within 24 hours in children diagnosed to have acute otitis media (AOM
group) and in children with RTI without AOM (non-AOM group). child’s verbal
expression of ear pain (B).
vomiting and found that mucus vomiting
was reported 10 times more frequently
than actual vomiting.2
In our study population.7°C [AOM group]. purulent middle-ear ﬂuid.aappublications. our nonAOM group had typical ﬁndings of
negative bacterial culture or nonexist-
FIGURE 3
Severity (none. 2015
e1159
.
Data were collected before tympanicmembrane examination. moderate. the symptom-based
components did not differ. It should be
noted that Shaikh et al16.
ence of middle-ear ﬂuid: retracted position of tympanic membrane and tympanometric C curve. rather. Although our
AOM diagnosis was based on pneumatic
otoscopy.24.33 Our approach was
based on what is daily encountered in
an outpatient setting: an acutely ill. The AAP’s criteria for
PEDIATRICS Volume 125. or severe) of
parentally reported ear pain (A). Similar to
the AOM-faces scale. both
based on symptoms and ear-related
signs. structured questionnaire for the symptom survey. were signiﬁcantly higher in children with AOM than in children with
only RTI. and tympanometric B curve. The horizontal lines show the highest
measured mean temperature of each group (38. even stricter than that of the
AAP. Because solely symptom-based
scores and the AAP’s deﬁnition of illness severity lead to similar results in
young symptomatic children with and
without AOM. which is somewhat subjective. Number 5. May 2010
severe illness is designed to determine the optimal treatment for AOM. because mucus vomiting is a respiratory
symptom rather than a gastrointestinal
symptom.
Applying the scores from recent literature to our data raised interesting and
new considerations.32 In contrast. it would be important to report these 2 symptoms separately. ear-rubbing (C). We had a prespeciﬁed deﬁnition
for AOM. 38.508). We
used a standardized. It is important to note that this
was because of the ear-related signs
of the scores. P ⫽ .30 developed
the AOM-SOS score not to determine
the severity of AOM but. and
irritability in the AOM and non-AOM groups (D).6°C [non-AOM group]. The clinical/otologic score and the AOM-Si score. On the basis of this
new ﬁnding.

Likewise.org by guest on March 3.011
. and researchers is that the
symptom-based scores can poorly differentiate young children with AOM
from those with only RTI.202
.928
.
The signiﬁcance of this study for the
otitis media authorities.429
Percentages may not total 100% because of rounding.
and the role of tympanic-membrane examination should be emphasized in the
FIGURE 4
Distributions of the score values in the AOM and non-AOM groups.
a Data were missing for 1 child in the AOM group. and also positive between AOM-SOS and AOM-faces scale within the AOM
group (r ⫽ 0.001). P ⬍ . n (%)
None
Mild
Severe
None
Mild
Severe
31 (13)
32 (14)
125 (53)
86 (36)
15 (6)
60 (25)
48 (20)
156 (66)
193 (81)
212 (89)
234 (99)
206 (87)
128 (54)
73 (31)
93 (39)
100 (42)
101 (43)
103 (43)
121 (51)
67 (28)
30 (13)
23 (10)
3 (1)
27 (11)
78 (33)
132 (56)
19 (8)
51 (22)
121 (51)
74 (31)
67 (28)
14 (6)
14 (6)
2 (1)
0 (0)
4 (2)
28 (12)
33 (14)
128 (55)
84 (36)
12 (5)
61 (26)
60 (26)
149 (64)
199 (86)
208 (90)
227 (98)
210 (91)
124 (53)
64 (28)
88 (38)
99 (43)
121 (52)
88 (38)
120 (52)
68 (29)
31 (13)
22 (9)
4 (2)
20 (9)
80 (34)
135 (58)
16 (7)
49 (21)
99 (43)
83 (36)
52 (22)
15 (6)
2 (1)
2 (1)
1 (0)
2 (1)
P
.
The limitations also must be elucidated. each child
has a different spectrum of symptoms
in different episodes of infections
caused by different microbes. Therefore.001). children with AOM
in our study may have had a different
proﬁle of symptoms than did children
with accidentally diagnosed AOM. Furthermore. the diagnosis and management
of AOM cannot be made by telephone
contact.462. In addition.550
. Children without AOM in our
study may have had more severe
symptoms than did children with RTI in
general. Our results cannot be generalized to older children with verbal skills. Even if children have the same diagnosis.910
.
CONCLUSIONS
AOM cannot be predicted by the occurrence. the methodology could have
been improved by asking the parents
to complete the questionnaire.aappublications. Accordingly.996
. The Spearman correlation coefﬁcient between the clinical/otologic and AOM-Si scores was positive within the AOM
group (r ⫽ 0.828
. treatment
recommendations should not be entirely based on symptom severity. P ⬍ .992
. All children with symptoms
that cause parental anxiety deserve
careful clinical examination. 2015
. including
cerumen removal followed by pneumatic otoscopy. each
one has an individual spectrum of
symptoms.
e1160
LAINE et al
Downloaded from pediatrics.
The message of our study for clinicians
and parents is that symptoms cannot
predict AOM at otitis-prone age. P ⬍ . solely symptom-based scores
do not differentiate RTI with and
without AOM. duration.001) and within the non-AOM group (r ⫽ 0. Therefore.746
.344.258.001) and within the non-AOM group (r ⫽ 0.386. if the severity scores are based
solely on symptoms. guideline-
makers. or severity of
symptoms at otitis-prone age.118
. 50th (median). We propose that the
scores also include evaluation of the
tympanic membrane.438
. our results
are not applicable to the entire age
group. Fi-
nally.
young child with anxious parents who
suspect AOM.TABLE 3 Severity of Symptoms in Children in the AOM and Non-AOM Groups
Symptom
Excessive crying
Restless sleep
Less playful or active
Poor appetite
Rhinitis
Nasal congestion
Cougha
Hoarse voice
Conjunctivitis
Mucus vomiting
Vomiting
Diarrhea
AOM Group (N ⫽ 237). n (%)
Non-AOM Group (N ⫽ 232).
Because we focused on children with
parental suspicion of AOM. P ⬍ . and 75th quartiles together with the minimum
and maximum values of each score. The boxplots show the 25th. the scoring actually depends more on the occurrence
of the symptoms than on the severity
of the symptoms.